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EXAMINATION OF THE CERVICAL SPINE1
THE AUSTRALIAN JOURNAL OF PHYSIOTHERAPY VOLUME 25
APRIL 1979
NUMBER 2
EXAMINATI0N OF THE CERVICAL SPINEl G.D. MAITLAND South Australian Institute of Technology Examination of the cervical spine is discussed briefly in relation to history, neurological examination, vertebrobasilar insufficiency and x-rays. The general principles of examining cervical movements are presented. Details of the examination are discussed in more detail under the following headings: the upper cervical spine and its examination for cervical headache; the middle cervical spine with its examination being related to spondylosis/arthrosis; the middle and lower cervical spine and its examination related to wry neck, nerve root irritation or compression, and whiplash injury. Before embarking on the physical examination of individual disorders at different levels of the cervical spine, there are five general aspects of examination relevant to all sections, which are better discussed seperately. This will enable emphasis to be placed on the particular aspects of examination which pertain to each section under its own heading.
GENERAL ASPECTS OF EXAMINATION History~·
It would occupy too much time now to discuss history in detail, particularly as it is fully discussed in many readily available texts. However, it is worth reminding physiotherapists that questioning f or such items as general health, relevant recent weight loss and previous illnesses (such as rheumatic fever), must not be forgotten. The socio-economic situation should also be investigated as applicable. Previous history can also provide the examiner with invaluable information related to the progress of a pathology.
Neurological examination: It is essential that any person involved in the treatment of cervical disorders should be capable of assessing altered nerve conduction in order to identify nerve root compression changes or changes due to a peripheral nerve
Based on a paper presented at "Conference on Headache, Neck and Arm Pain ", Western Australian Physiotherapy Association, November 1977. 1
Aust. J. Physiother., 25, 2, April, 1979
compression. Questioning and tests to discover spinal cord involvements are other vital skills. Further mention of nerve root compression will be made later.
Vertebrobasilar insufficiency: When the treatment of the cervical spine includes manipulation, methods of examining for vertebrobasilar insufficiency, both by questioning and physical tests, need to be understbod, proficiently carried out and accurately interpreted. For example, a patient may complain that if he looks overhead he feels dizzy. This may that there is vertebrobasilar involvement in this neck position. To determine whether it is cervical positioning causing the dizziness, the patient should be asked to lie prone and then extend his head and neck. If the cervical spine is involved, then this same neck position will reproduce the Sattle dizziness; if the dizziness is not reproduced, the cervical spine is unlikely to be involvio!d. Similarly, if a patient complains that turning his head from side to side makes him dizzy, the differential physical test movement should involve holding the patient's head still while he stands and twists his trunk beneath his stabilised head, thus still fully rotating his neck from side to side, but without head movement. Again, if the cervical spine is involved, the dizziness will be reproduced despite the fact that his head is not moving. Sustained rotation to each side should be tested whenever vertebrobasilar insufficiency is suspected, as should sustained extension. Other tests for 'cervical vertigo', as discussed by Cope and Ryan (1955; 1959) may need to be utilised. There are two other circumstances when the 49
CER VICAL SPINE EXAMINA TION vertebral artery should be remembered during passive movement treatment. They are, firstly, the elderly patient who mentions that he .has dizziness when standing from lying or bendmg, and secondly, the patient who has radiolog~c~l evidence of marked spondylitic and arthrItIc changes. Such symptoms and signs call for ca,ltion with treatment.. X-.rays:
When the cervical spine is to be treated using passive movement techniques in particular, X-rays are mandatory. However, they may not be essential if the techniques only involve mobilisation.
lt1ovements: When the normal functional physiological
movements of the cervical spine are examined, that is, the movements of flexion, extension, lateral flexion and rotation, note should be made of the range of movement, the pattern of intervertebral movement, the behaviour of local pain with movement and the behaviour of referred pain with movement. The aim of testing movements is to achieve one of two ends:
- To reproduce the patient's symptoms. This statement needs to be qualified. When the patient has severe or moderately severe nerve root pain, the examiner chooses not to reproduce part or all of the arm pain. - When to reproduce the patient's referred symptoms is either not possible or not advisable, the aim of the examination technique is to find comparable joint signs at an appropriate intervertebral joint. 'fhese same principles of assessing range and local pain are also applied to the passive movements which can be tested at each intervertebral joint. These individual passive intervertebral test movements are of two kinds. The first involves moving the cervical spine while palpating between palpable parts of adjacent vertebrae to assess range. The second involves assessing the range, pain and the presence of any muscle spasm, by moving individual vertebrae through pressures exerted directly against palpable parts of each vertebra. Having discussed some of the general features in relation to examination, the following discussion will be related to particular disorders which occur at different levels of the vertebral column~
UPPER CERVICAL SPINE Cervicul headache: This condition, particularly in the elderly, is extremely common and unfortunately not
so
enough doctors or physiotherapists appreciate that it is extremely amenable to mobilisation. In examination for cervical headache of upper cervical origin, the following are the particular points to be emphasised..
Area of pain: If pain is felt in relation to the occiput and
the upper cervical spine, it is particularly impart ant to be able to identify the precise area of the symptoms by asking the patient to point to the area with the tip of the index finger or by the examiner using his or her own finger to identify it. This will give a clear lead as to whether one is likely to be examining for an atlanto-occipital, atlanto..axial, or C2/3 joint problem. The precise area of symptoms occupying the anterior three-quarters of the head is also important, particularly in reference to determining whether the symptoms possibly involve the occipital nerves. Bilateral symmetrical frontal pain is common and is uninformative, whereas localised unilateral frontal or parietal pain is significan t.
When pain encompasses the whole head it is necessary to determine whether the symptoms have a unilateral dominance or not, and when there is asymmetry it is necessary to know whether it can be either side or whether it is always on the one side. The 'kind' of pain is also important because if it is general and of nuisance value then treatment can be expected to be quick and effective, whereas if the symptoms are throbbing or stabbing in nature, the response to treatment can be expected to be slower.
Neurological:
It should not be forgotten that there may be altered scalp sensation if one of the occipital nerves is involved; therefore a neurological test of sensation should be undertaken. Physiological: Flexion, extension, lateral flexion and rotation should be routinely examined and overpressure, emphasising the movement to the upper cervical spine, should be applied at the limit of the painless range so as to be certain that the movement is, in fact, normal. There are three special movements which should be examined for the upper cervical spine.
- Ask the patient to forcibly poke his chin forward as far as possible and then to retract the head with a fully chin-in position. These movements emphasise maximum extension and flexion respectively to the high cervical area. If both movemt:'.nts are painless the examiner
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND should apply overpressure to the movements at the limit of the range. - The upper cervical quadrant is a test movement which, if done towards the left, jams shut the high cervical joints on the left and stretches the high cervical joints on the right. To test the left quadrant for the left side of the upper cervical spine, the physiotherapist stands by the left side of the patient and guides his head into extension and applies pressure to localise the movement to the upper cervical joints. This is done by grasping the patient's chin from underneath in the left hand and his forehead in the right. At the same time his trunk should be stabilised by the physiotherapist's arm from behind and her side from in front, while she applies pressure through her hands to flex the lower cervical spine with the head held in extension. While head extension is maintained, rotation to the left is added. The axis of rotation has changed from the vertical, when the head is in an upright position, to atomst horizontal, when the head is in full extension. It is the head which is turned and the technique is to produce oscillatory movements so that the limit of the rotatory range can be felt. When the head is fully turned towards the physiotherapist she then adds the lateral flexion component. The lateral flexion movement involves tilting the crown of the patient's head towards her and his chin away from her. This movement is also performed in an oscillatory fashion until the limit of the range is reached. This is a very difficult test movement to carry out accurately and much practice is necessary to perform it well (see Figure 1).
-,--)
FIGURE 1: THE UPPER QUADRANT TEST POSITION.
CERVICAL
- Compression and distraction are two movements which should be applied to the upper cervical joints. Compression involves the patient sitting with the physiotherapist standing
Aust. J. Physiother., 25, 2, April, 1979
behind the patient with her hands cupped over the crown of his head. She gently applies pressure through his head as a small amplitude oscillatory pressure gradually increasing the strength of the pressure until pain is initiated or the compression test is found to be pain free. Similarly, with the patient sitting and the physiotherapist holding his occiput and chin in her hands, she gently lifts his head to see if symptoms are either provoked or relieved by this distraction.
Palpation: There are several important aspects to examination of the upper cervical spine by palpation. The first three are related to soft tissue, bony contour and position of vertebrae.
Soft tissue. This involves palpation, particularly of the sub-occipital muscles from the midline to the lateral margin of the articular pillar between the occiput and the lower border of C3. The purpose of the examination is to appreciate muscle spasm or thickening. Secondly, it is possible to determine the state of the capsule of the atlanto-occipital joints, and to some extent, the atlanto-axial joints and the apophyseal joints between C2 and C3. It is also possible to determine the state of the interspinous ligaments and ligamentum nuchae by careful palpation with the tip of the index finger. Bony contour. Here again it is possible by careful palpation to determine whether there are any marked arthritic changes of the apophyseal joints between Cl , C2 and C3. Position of vertebrae. By palpation it is possible to determine whether the atlas is symmetrically positioned beneath the occiput, both in the anteroposterior direction on one side, or both sides, and also in a lateral displacement direction. Similarly it is possible to appreciate rotation between the atlas and axis if the spinous process of C2 is displaced to, say, the left concurrently with a backward displacement of the articular pillar of C2 on the right. However, it should be pointed out that both the direction and slope of the spinous processes of C2 and C3, especially C2, are notoriously distorted without any rotational element of the body of the vertebra. By similar palpation it is possible to determine whether there is any rotation or lateral flexion (which are usually combined when present) between C2 and C3. All of the above tests by palpation should be performed with the patient lying prone with his forehead resting in the palms of his hands and his elbows projecting laterally. The next important aspect to examination by palpation is among the most informative. It involves applying pressure, using the thumbs 51
CERVICAL SPINE EXAMINATION against the articular pillar, the occipita-atlantal (Figure 3). The movement is produced by a joints, the arch of the atlas, and the spinous trunk and arm action transmitted to the processes of C2 and C3. These tests are used to thumbs which act as springs. Although the determine the relationships between range of movement is created by a postero-anterior movement, quality of movement, protective pressure against C2, it is in fact increasing the muscle spasm, and the behaviour of local or rotation between Cl and C2. referred pain during the movement. Each of the tests has been described fully elsewhere MIDDLE CERVICAL SPINE (Maitland, 1977). Reference to Figure 2 will show how the directions of the pressures can be Spondy losis/Arthrosis: varied from postero-anteriorly to having a The presenting symptoms being considered medial inclination, a lateral inclination, a under this heading are those of general cephalad inclination or caudad inclination. Also neckache and discomfort made worse when the combinations of any of these may be utilised. head is turned fully to either side. It is really an exacerbation of otherwise very mild symptoms constantly felt in the neck of the elderly patient who has radiological evidence of marked general spondylitic and arthrotic changes in the cervical spine. Even when the patien t is virtually pain free his movements are limited in all directions. There are three important parts of examination. They are physiological rotation, palpation, and assessment of abnormals.
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I
t
(
j
, .....
FIGURE 2: POSTEROANTERIOR PRESSURES WITH DIFFERENTLY ANGLED INCLINATIONS. One further palpation test for movement is vital in this area. It involves testing the range and pain by palpating the atlanta-axial joint in a position of rotation. Because of its importance as an examination procedure for upper cervical headache, and because performance of this technique as a sustained oscillatory stretch will frequently reproduce the patient's headache, the technique is described in full. The patient lies prone with his head turned approximately 30° to the left, placing his forehead in his palms. The physiotherapist stands at his head and places the tips of both thumbs, their nails back to back, against the articular pillar of C2 on the left. (This articular pillar can be found in relation to the spinous process of e2, which will be unchanged from the position it held when the head was straight.) Her fillgers spread to each side of the patient's neck to stabilise the hands. She holds her thumbs in opposition and directs the long axis of each thumb in a postero-anterior direction and inclines them slightly towards the head 52
Physiological rotation: Although all movements should be examined the main test movement is rotation. It should be done in a particular way. The patient should be asked to turn his head as far as possible to one side and to report the site of any discomfort he may feel. The examiner should then, in a very controlled way, apply careful over-pressure to the rotation noting changes in the behaviour of pain, hoping to be able to reach a point in the range where fractional increase in the over-pressure produces a sharp increase in pain. When this does occur that fractional increase in over-pressur~ is immediately released. This test movement should be made with rotation to each side. This can be considered to be an abnormal reaction to over-pressure with stiff rotation and it is one of the important presenting signs which have to be 'cleared'.
Palpation: Palpation of the cervical spine between C2 and CS or C6 is the same as that described above for the upper cervical spine in relation to soft tissue, bony contour, position of vertebrae, and the relationships found between range and pain during the movement tests by palpation. These findings equal, in importance, the finding on applying over-pressure to rotation described above. Normal-abnormals compared with abnormalabnormals. The spondylitic/arthrotic cervical spine showing marked degenerative changes in the Aust. J" Physiother., 25, 2, April, 1979
MAITLAND elderly is a common and almost asymptomatic condition. In the asymptomatic stage, examination of movements by over-pressure and palpation as described above will produce only minimal symptoms even though the range will be markedly limited. Such examination findings can be considered to be 'normalabnormal'. On the other hand, when overpressure applied to rotation, referred to above, causes a sharp increase in pain, and when pain is also found on the movement tests by palpation, these findings are abnormal findings superimposed on the already abnormal cervical spine. They are, however, signs which can be 'cleared'. These signs are what is meant by the term 'abnormal-abnormals'.
MIDDLE AND LOWER CERVICAL SPINE Wry Neck: Of the musculoskeletal type of disorders being considered in this paper, there are two distinct yet similar entities which present commonly. Both have a protective deformity of the cervical spine but there are subtle differences in the history, deformity and site of pain, and the management of each is different. Wry Neck (possible apophyseal joint) History.· The onset is sudden and associated with movement causing immediate neck pain, and immediately preventing any hope of returning the head and neck to the straight position.
Site of pain: The pain will be felt on the side of the neck away from which the head is tilted and this pain will be felt within 5 cm of the midline ranging between the levels of C2 and C7 . Protective deformity: The deformity will consist of varying degrees of lateral flexion away from the side of pain, rotation away from the side of pain and flexion. The element of particular importance in the protective deformity of this entity is that the flexion and rotation components will not be large. Examination movements: With the patient sitting, it will be quite impossible to bring the patient's head and neck into the normal erect straight-on position even if the greatest care to avoid pain is exercised. Palpation for movement on the side of the convexity, using postero-anterior pressure on the articular pillar, (particularly if this posteroanteriar pressure is directed medially), will clearly identify precisely which intervertebral level is involved. Testing for passive physiological intervertebral movement in the direction of lateral flexion will also clearly define the inter-
FIGURE 3: ASSESSING ATLANTO-AXIAL ROTATION. Aust. J. Physiother., 25, 2, April, 1979
53
CERVICAL SPINE EXAMINATION vertebral segment involved. To test in this manner skilfully and expertly requires practice. The following is the description of the technique. C2-C7 (lateral flexion) Starting position: The patient lies supine with his head resting on the table on a pillow, or in the physiotherapist's lap4 The position chosen should facilitate relaxation and it should support the bead and neck midway between flexion and extension for the joint being examined. In this position both lateral flexion and rotation are most free. The physiotherapist places the tip of her index finger into the interlaminar space deeply enough to palpate adjacent laminae. With both hands, particularly the non-palpating hand, she must give adequate support under the occiput. When the lower cervical movements are tested, this support extends under the neck. Method: Being careful to ensure that the joint being tested is moving and not just the head on the neck, the physiotherapist first laterally flexes the joint towards her palpating finger and assesses the extent of closing of the inter-laminar space. The opposite movement is then performed to asses the opening of the space. By this means the excursion of lateral flexion at the Intervertabral level on the SIde beIng tested can clearly be evaluated. The palpating finger tip must remain motionless in the space, so care must be exercised when that finger is used to produce the lateral flexion of the neck.
FIGURE 4: PAIN SCAPULAR AREA4
REFERRAL
TO THE
Protective deformitY.4 As with the previously described disorder, the deformity consists of lateral flexion and rotation away from the side of pain and flexion. The difference between the two deformities is that with this disorder the flexion component of the deformity can be at least equal to the lateral flexion component, if not the main component.
History: The history of this entity is commonly one where the patient reports waking in the morning with a stiff neck. He may, on specific questioning, eventually recall some minor incident of having mildly hurt his neck the previous day The important element in the history which differentiates this kind of protective deformity from the previous entity is that the patient is not wakened during the night by pain, as would have been the case with the above disorder, but rather wakens in the morning with a stiff neck and pain4
Examination movements~' As with the above disorder, when the patient is sitting his head cannot be returned to the upright position, though there is less sharp muscle contraction resisting attempts by the examiner to bring the head upright. On examination by palpation movements, and on examination for the range by passive physiological intervertebral movements (both described above), it is impossible to localise the loss of range to one intervertebral joint; rather the lack of movement is felt to be distributed over three, or more, intervertebrallevels It was stated that the treatment of the two entities is different. The first kind of Wry Neck can be dramatically relieved in one treatment by manipulation or mobilisation. For the second kind of Wry Neck, traction in flexion and sustained oscillatory stretching type rotation of the head away from the painful side will assist spontaneous recovery over a period of days; the greater the flexion deformity, the longer the time taken to achieve the recovery.
Site of pain:
Nerve Root Irritation or Compression:
The pain is felt commonly at the root of the neck on the side away from which the patient tilts his head, and this pain may spread down into the scapular area. In relation to the clinical
When a patient has pain which may be of nerve root distribution and character, this pain mayor may not be accompanied by signs of altered nerve conduction (reflex activity,
Wry Neck (possible discogenic)
4
54
4
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND sensory change and muscle weakness). If nerve root changes are not present the condition is often referred to as one of 'nerve root irritation', whereas when neurological changes are present the condition is usually described as 'nerve root compression'. In the cervical spine, at least, there is no doubt that either irritation or compression of the nerve root can result from disturbances of the disc or the apophyseal joints. This paper concerns itself with the patient who has moderately severe pain spreading the full length of the upper limb, with movements which are limited and reproduce limb pain, but where there is no immediate call for surgery.
Subjective examination: The history, site of pain and behaviour of symptoms are directly relevant in arriving at a probable diagnosis and indication of prognosis. This aspect will not be dealt with in detail in this paper.
Neurological examination: This aspect also will only briefly be mentioned here.. It suffices to say that the therapist must be capable of a very exact examination of individual muscle power, sensation and reflex activity, as well as being able to interpret the findings in terms of which nerve root is involved and the probable intervertebral level involved. In the cervical spine, w hen neurological examination indicates that more than one nerve root is causing the compression signs, this should be seen as a danger signal because it indicates that the disorder is not one which should be being managed by the physiotherapist. It is probably useful to state in this section that C7 is the most common nerve root involved; C6 runs second with C8 and C5 being far less common. When C8 is involved, thoughts of disorders other than disc prolapse should be kept in mind.. When examining the movements of patients who fit into this category, it is necessary to decide whether the movements should be tested up to the point in the range where pain commences or begins to increase, or, on the other hand, whether the movements need to be taken to the limit of the range. When pain is severe or the symptoms are very easily provoked or tend to remain exacerbated, the test movements should only be taken to the point where pain begins. However, movements may be taken beyond this point as will be indicated and described in the section which follows. When a patient's symptoms are mild and chronic, it is probable that the test
Aust.. J. Physiother., 25, 2, April, 1979
movements will need to be taken to the limit of the range. The following examination procedure is that adopted for p~tients with severe pain, with test movements beIng taken to the point of pain.
Passive movement tests: Tests for movement by palpation and tests for passive physiological intervertebral movement have almost no place in the examination of this disorder..
Physiological movement tests: Examination of these movements, with emphatic reference to the behaviour of pain with test movements of this kind, are vital to the assessment and management of this disorder. The movements of flexion, extension, lateral flexion and rotation should be examined with care. The kind of care implied is embodied in the following description of testing, say, lateral flexion towards the side of pain. The steps for the test are as follows . 1. The patient is asked what pain or discomfort he has before testing the movement. 2. The therapist gently holds the patient's head in her hands and asks the patient to tilt his head towards the side of pain, insisting that he stop immediately there is any increase in any part of the symptoms. 3. When the patient stops, the therapist immediately returns the patient's head to the upright position and determines where that pain was felt . 4. Supposing the pain was felt in the scapular area, the movement is repeated to that same point in the range, and the patient's head is held stationary in that position to see whether the pain changes in intensity or area over a period of, say, six seconds. 5. If there is no increase in area of the pain, the movement is carried further into the painful range, the patient having been asked to report immediately any spread of the pain. 6. Immediately the patient indicates any increase in area, the patient's head is returned to the upright position so that the therapist can determine to where the pain had spread. 7. Let us suppose that the pain spread into the upper triceps area. When the patient's head has been returned to the upright position the therapist needs to be certain of the length of time taken for the symptoms to return to their pre-examination intensity and area. 8. When the symptoms have subsided, the movement is repeated to that point in the range where the pain was felt in the triceps. It is then sustained in that position to see whether, over a period of some seconds, the pain spreads further.
55
CER VICAL SPINE EXAMINA TION 9. If the pain spreads further with a sustained position, the head is returned to the upright position and notice is taken of the length of time taken for that pain to subside and the test is completed. 10. If the pain does not spread further with the sustained position, the movement is carried slightly further into the range to see whether the pain spreads further into the arm. 11. If the pain does spread further into the arm, the head is returned to the upright position so that the area of spread can be noted as well as noting the time taken for the pain to subside. 12. If the pain has spread further down the upper arm or reaches into the forearm, the test is then over. With this kind of careful examination it is possible to determine in detail the behaviour of pain associated with movement. It must also be remembered that, although the movement may not increase the intensity or area of the pain at the time of the movement, there is the possibility of latent referred pain which follows movement rather than occurring at the time of movement. Assessment of this behaviour is equally as important, if not more important, than the above. The three movements which commonly reproduce the referred pain are lateral flexion towards the side of pain, rotation towards the side of pain, and extension~ The above description is for those patients whose symptoms are severe and easily exacerbated. The second group consists of those patients whose symptoms are not severe and may be considered chronic. When their pain is not reproduced by these movements, then each of the three movements, lateral flexion towards pain, rotation towards pain, and extension, should be performed as full range movements with slight over-pressure being applied at the limit of the range. This oscillatory over-pressure should be maintained for at least 10 seconds to assess whether the sustaining of the position will reproduce part of the referred symptoms. If the symptoms are not reproduced, then the head is restored to the upright position and a short time, for example, 10 seconds, should be allowed so that assessment of latent pain, referred to above, may be made. There are two other tests which should be undertaken when all of the previous tests have failed to reproduce the symptoms. The first is to examine the lower cervical quadrant. The technique for testing the lower cervical spine by this 'quadrant' movement varies appreciably from that used for the upper cervical spine. To test the lower cervical spine for left-sided pain 56
the neck is tilted back into the left corner until the lower cervical spine is fully extended, laterally flexed to the left and rotated to the left (Figure 5).
FIGURE 5: THE LOWER QUADRANT TEST POSITION.
CERVICAL
The last test involves the application of sustained compression through the head and directed towards the feet, while the patient's head is tilted into slight lateral flexion towards the side of pain and minimal extension. This compression should be applied gently at first, feelingly and with a small degree of oscillation so that the strength of the movement and its effect on symptoms can be continually assessed. Pressure should only be increased if referred pain is not reproduced, and, as with the tests described above, following release of the pressure, a period of waiting should be allowed so that any latent pain can be assessed. Enormously valuable information can be derived from these tests, and they play an immensely important part in the assessment and management of such disorders. When examining patients whose symptoms are chronic in nature, the value of the examination procedures, involving movement by palpation over the articular pillar and spinous processes of the lower cervical vertebrae, is important. However, when symptoms are severe, such examination is unnecessary; the physiological test movements provide all the information that is necessary ~ Whiplash Injury: When a patient's symptoms result from a recent whiplash type injury, the muscles should be tested as a source of pain because they are
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND commonly directly involved by the trauma. They are tested by isometric contractions, starting gently and gradually increasing the strength of the muscular contraction. However, such tests do not supply unequivocal answers because as soon as the muscles are made to contract there is immediately a degree of joint movement. Therefore, when pain is created by the isometric contraction it is difficult to tell how much of this pain is due to the contraction of the muscle and how much is due to the joint movement. It is only by making a comparison between the site and the degree of pain with the isometric contraction, as compared with that produced during an active movement, that any assessment can be made. Muscle tests in disorders other than those caused by trauma usually prove to be uninformative
ACKNOWLEDGMENTS Thanks are due to Butterworths, London, for permission to reproduce text and figures from "Vertebral Manipulation", 4th Edition, 1977, and to Mr David Thompson and the Audio
57
Visual Aids Department of the South Australian Institute of Technology for their part in producing the figures. I would also like to thank Dr. R. Cloward for his helpfulness and generosity in allowing me to refer to his valuable contribution and to reproduce his material.
REFERENCES CLOWARD,R.B. (1960): The Clinical Significance of the Sinu-Vertebral Nerve in Relation to the Cervical Disc Syndrome. Journal ofNeurology, Neurosurgery and Psychiatry, 23:321326~
COPE, S. and RYAN, G.M.S. (1955): "Cervical Vertigo", Lancet, 2: 1355-1358. COPE, S. and RYAN,G.M.S. (1959): "Cervical and Otolith Vertigo". Journal Laryngology and Otology, 73:113-120.
MAITLAND, G.D. (1977): "Vertebral Manipulation", 4th Edition, Butterworths,
London.
Aust. J. Physiother., 25, 2, April, 1979
APRIL 1979
NUMBER 2
EXAMINATI0N OF THE CERVICAL SPINEl G.D. MAITLAND South Australian Institute of Technology Examination of the cervical spine is discussed briefly in relation to history, neurological examination, vertebrobasilar insufficiency and x-rays. The general principles of examining cervical movements are presented. Details of the examination are discussed in more detail under the following headings: the upper cervical spine and its examination for cervical headache; the middle cervical spine with its examination being related to spondylosis/arthrosis; the middle and lower cervical spine and its examination related to wry neck, nerve root irritation or compression, and whiplash injury. Before embarking on the physical examination of individual disorders at different levels of the cervical spine, there are five general aspects of examination relevant to all sections, which are better discussed seperately. This will enable emphasis to be placed on the particular aspects of examination which pertain to each section under its own heading.
GENERAL ASPECTS OF EXAMINATION History~·
It would occupy too much time now to discuss history in detail, particularly as it is fully discussed in many readily available texts. However, it is worth reminding physiotherapists that questioning f or such items as general health, relevant recent weight loss and previous illnesses (such as rheumatic fever), must not be forgotten. The socio-economic situation should also be investigated as applicable. Previous history can also provide the examiner with invaluable information related to the progress of a pathology.
Neurological examination: It is essential that any person involved in the treatment of cervical disorders should be capable of assessing altered nerve conduction in order to identify nerve root compression changes or changes due to a peripheral nerve
Based on a paper presented at "Conference on Headache, Neck and Arm Pain ", Western Australian Physiotherapy Association, November 1977. 1
Aust. J. Physiother., 25, 2, April, 1979
compression. Questioning and tests to discover spinal cord involvements are other vital skills. Further mention of nerve root compression will be made later.
Vertebrobasilar insufficiency: When the treatment of the cervical spine includes manipulation, methods of examining for vertebrobasilar insufficiency, both by questioning and physical tests, need to be understbod, proficiently carried out and accurately interpreted. For example, a patient may complain that if he looks overhead he feels dizzy. This may that there is vertebrobasilar involvement in this neck position. To determine whether it is cervical positioning causing the dizziness, the patient should be asked to lie prone and then extend his head and neck. If the cervical spine is involved, then this same neck position will reproduce the Sattle dizziness; if the dizziness is not reproduced, the cervical spine is unlikely to be involvio!d. Similarly, if a patient complains that turning his head from side to side makes him dizzy, the differential physical test movement should involve holding the patient's head still while he stands and twists his trunk beneath his stabilised head, thus still fully rotating his neck from side to side, but without head movement. Again, if the cervical spine is involved, the dizziness will be reproduced despite the fact that his head is not moving. Sustained rotation to each side should be tested whenever vertebrobasilar insufficiency is suspected, as should sustained extension. Other tests for 'cervical vertigo', as discussed by Cope and Ryan (1955; 1959) may need to be utilised. There are two other circumstances when the 49
CER VICAL SPINE EXAMINA TION vertebral artery should be remembered during passive movement treatment. They are, firstly, the elderly patient who mentions that he .has dizziness when standing from lying or bendmg, and secondly, the patient who has radiolog~c~l evidence of marked spondylitic and arthrItIc changes. Such symptoms and signs call for ca,ltion with treatment.. X-.rays:
When the cervical spine is to be treated using passive movement techniques in particular, X-rays are mandatory. However, they may not be essential if the techniques only involve mobilisation.
lt1ovements: When the normal functional physiological
movements of the cervical spine are examined, that is, the movements of flexion, extension, lateral flexion and rotation, note should be made of the range of movement, the pattern of intervertebral movement, the behaviour of local pain with movement and the behaviour of referred pain with movement. The aim of testing movements is to achieve one of two ends:
- To reproduce the patient's symptoms. This statement needs to be qualified. When the patient has severe or moderately severe nerve root pain, the examiner chooses not to reproduce part or all of the arm pain. - When to reproduce the patient's referred symptoms is either not possible or not advisable, the aim of the examination technique is to find comparable joint signs at an appropriate intervertebral joint. 'fhese same principles of assessing range and local pain are also applied to the passive movements which can be tested at each intervertebral joint. These individual passive intervertebral test movements are of two kinds. The first involves moving the cervical spine while palpating between palpable parts of adjacent vertebrae to assess range. The second involves assessing the range, pain and the presence of any muscle spasm, by moving individual vertebrae through pressures exerted directly against palpable parts of each vertebra. Having discussed some of the general features in relation to examination, the following discussion will be related to particular disorders which occur at different levels of the vertebral column~
UPPER CERVICAL SPINE Cervicul headache: This condition, particularly in the elderly, is extremely common and unfortunately not
so
enough doctors or physiotherapists appreciate that it is extremely amenable to mobilisation. In examination for cervical headache of upper cervical origin, the following are the particular points to be emphasised..
Area of pain: If pain is felt in relation to the occiput and
the upper cervical spine, it is particularly impart ant to be able to identify the precise area of the symptoms by asking the patient to point to the area with the tip of the index finger or by the examiner using his or her own finger to identify it. This will give a clear lead as to whether one is likely to be examining for an atlanto-occipital, atlanto..axial, or C2/3 joint problem. The precise area of symptoms occupying the anterior three-quarters of the head is also important, particularly in reference to determining whether the symptoms possibly involve the occipital nerves. Bilateral symmetrical frontal pain is common and is uninformative, whereas localised unilateral frontal or parietal pain is significan t.
When pain encompasses the whole head it is necessary to determine whether the symptoms have a unilateral dominance or not, and when there is asymmetry it is necessary to know whether it can be either side or whether it is always on the one side. The 'kind' of pain is also important because if it is general and of nuisance value then treatment can be expected to be quick and effective, whereas if the symptoms are throbbing or stabbing in nature, the response to treatment can be expected to be slower.
Neurological:
It should not be forgotten that there may be altered scalp sensation if one of the occipital nerves is involved; therefore a neurological test of sensation should be undertaken. Physiological: Flexion, extension, lateral flexion and rotation should be routinely examined and overpressure, emphasising the movement to the upper cervical spine, should be applied at the limit of the painless range so as to be certain that the movement is, in fact, normal. There are three special movements which should be examined for the upper cervical spine.
- Ask the patient to forcibly poke his chin forward as far as possible and then to retract the head with a fully chin-in position. These movements emphasise maximum extension and flexion respectively to the high cervical area. If both movemt:'.nts are painless the examiner
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND should apply overpressure to the movements at the limit of the range. - The upper cervical quadrant is a test movement which, if done towards the left, jams shut the high cervical joints on the left and stretches the high cervical joints on the right. To test the left quadrant for the left side of the upper cervical spine, the physiotherapist stands by the left side of the patient and guides his head into extension and applies pressure to localise the movement to the upper cervical joints. This is done by grasping the patient's chin from underneath in the left hand and his forehead in the right. At the same time his trunk should be stabilised by the physiotherapist's arm from behind and her side from in front, while she applies pressure through her hands to flex the lower cervical spine with the head held in extension. While head extension is maintained, rotation to the left is added. The axis of rotation has changed from the vertical, when the head is in an upright position, to atomst horizontal, when the head is in full extension. It is the head which is turned and the technique is to produce oscillatory movements so that the limit of the rotatory range can be felt. When the head is fully turned towards the physiotherapist she then adds the lateral flexion component. The lateral flexion movement involves tilting the crown of the patient's head towards her and his chin away from her. This movement is also performed in an oscillatory fashion until the limit of the range is reached. This is a very difficult test movement to carry out accurately and much practice is necessary to perform it well (see Figure 1).
-,--)
FIGURE 1: THE UPPER QUADRANT TEST POSITION.
CERVICAL
- Compression and distraction are two movements which should be applied to the upper cervical joints. Compression involves the patient sitting with the physiotherapist standing
Aust. J. Physiother., 25, 2, April, 1979
behind the patient with her hands cupped over the crown of his head. She gently applies pressure through his head as a small amplitude oscillatory pressure gradually increasing the strength of the pressure until pain is initiated or the compression test is found to be pain free. Similarly, with the patient sitting and the physiotherapist holding his occiput and chin in her hands, she gently lifts his head to see if symptoms are either provoked or relieved by this distraction.
Palpation: There are several important aspects to examination of the upper cervical spine by palpation. The first three are related to soft tissue, bony contour and position of vertebrae.
Soft tissue. This involves palpation, particularly of the sub-occipital muscles from the midline to the lateral margin of the articular pillar between the occiput and the lower border of C3. The purpose of the examination is to appreciate muscle spasm or thickening. Secondly, it is possible to determine the state of the capsule of the atlanto-occipital joints, and to some extent, the atlanto-axial joints and the apophyseal joints between C2 and C3. It is also possible to determine the state of the interspinous ligaments and ligamentum nuchae by careful palpation with the tip of the index finger. Bony contour. Here again it is possible by careful palpation to determine whether there are any marked arthritic changes of the apophyseal joints between Cl , C2 and C3. Position of vertebrae. By palpation it is possible to determine whether the atlas is symmetrically positioned beneath the occiput, both in the anteroposterior direction on one side, or both sides, and also in a lateral displacement direction. Similarly it is possible to appreciate rotation between the atlas and axis if the spinous process of C2 is displaced to, say, the left concurrently with a backward displacement of the articular pillar of C2 on the right. However, it should be pointed out that both the direction and slope of the spinous processes of C2 and C3, especially C2, are notoriously distorted without any rotational element of the body of the vertebra. By similar palpation it is possible to determine whether there is any rotation or lateral flexion (which are usually combined when present) between C2 and C3. All of the above tests by palpation should be performed with the patient lying prone with his forehead resting in the palms of his hands and his elbows projecting laterally. The next important aspect to examination by palpation is among the most informative. It involves applying pressure, using the thumbs 51
CERVICAL SPINE EXAMINATION against the articular pillar, the occipita-atlantal (Figure 3). The movement is produced by a joints, the arch of the atlas, and the spinous trunk and arm action transmitted to the processes of C2 and C3. These tests are used to thumbs which act as springs. Although the determine the relationships between range of movement is created by a postero-anterior movement, quality of movement, protective pressure against C2, it is in fact increasing the muscle spasm, and the behaviour of local or rotation between Cl and C2. referred pain during the movement. Each of the tests has been described fully elsewhere MIDDLE CERVICAL SPINE (Maitland, 1977). Reference to Figure 2 will show how the directions of the pressures can be Spondy losis/Arthrosis: varied from postero-anteriorly to having a The presenting symptoms being considered medial inclination, a lateral inclination, a under this heading are those of general cephalad inclination or caudad inclination. Also neckache and discomfort made worse when the combinations of any of these may be utilised. head is turned fully to either side. It is really an exacerbation of otherwise very mild symptoms constantly felt in the neck of the elderly patient who has radiological evidence of marked general spondylitic and arthrotic changes in the cervical spine. Even when the patien t is virtually pain free his movements are limited in all directions. There are three important parts of examination. They are physiological rotation, palpation, and assessment of abnormals.
~ ,.
I
t
(
j
, .....
FIGURE 2: POSTEROANTERIOR PRESSURES WITH DIFFERENTLY ANGLED INCLINATIONS. One further palpation test for movement is vital in this area. It involves testing the range and pain by palpating the atlanta-axial joint in a position of rotation. Because of its importance as an examination procedure for upper cervical headache, and because performance of this technique as a sustained oscillatory stretch will frequently reproduce the patient's headache, the technique is described in full. The patient lies prone with his head turned approximately 30° to the left, placing his forehead in his palms. The physiotherapist stands at his head and places the tips of both thumbs, their nails back to back, against the articular pillar of C2 on the left. (This articular pillar can be found in relation to the spinous process of e2, which will be unchanged from the position it held when the head was straight.) Her fillgers spread to each side of the patient's neck to stabilise the hands. She holds her thumbs in opposition and directs the long axis of each thumb in a postero-anterior direction and inclines them slightly towards the head 52
Physiological rotation: Although all movements should be examined the main test movement is rotation. It should be done in a particular way. The patient should be asked to turn his head as far as possible to one side and to report the site of any discomfort he may feel. The examiner should then, in a very controlled way, apply careful over-pressure to the rotation noting changes in the behaviour of pain, hoping to be able to reach a point in the range where fractional increase in the over-pressure produces a sharp increase in pain. When this does occur that fractional increase in over-pressur~ is immediately released. This test movement should be made with rotation to each side. This can be considered to be an abnormal reaction to over-pressure with stiff rotation and it is one of the important presenting signs which have to be 'cleared'.
Palpation: Palpation of the cervical spine between C2 and CS or C6 is the same as that described above for the upper cervical spine in relation to soft tissue, bony contour, position of vertebrae, and the relationships found between range and pain during the movement tests by palpation. These findings equal, in importance, the finding on applying over-pressure to rotation described above. Normal-abnormals compared with abnormalabnormals. The spondylitic/arthrotic cervical spine showing marked degenerative changes in the Aust. J" Physiother., 25, 2, April, 1979
MAITLAND elderly is a common and almost asymptomatic condition. In the asymptomatic stage, examination of movements by over-pressure and palpation as described above will produce only minimal symptoms even though the range will be markedly limited. Such examination findings can be considered to be 'normalabnormal'. On the other hand, when overpressure applied to rotation, referred to above, causes a sharp increase in pain, and when pain is also found on the movement tests by palpation, these findings are abnormal findings superimposed on the already abnormal cervical spine. They are, however, signs which can be 'cleared'. These signs are what is meant by the term 'abnormal-abnormals'.
MIDDLE AND LOWER CERVICAL SPINE Wry Neck: Of the musculoskeletal type of disorders being considered in this paper, there are two distinct yet similar entities which present commonly. Both have a protective deformity of the cervical spine but there are subtle differences in the history, deformity and site of pain, and the management of each is different. Wry Neck (possible apophyseal joint) History.· The onset is sudden and associated with movement causing immediate neck pain, and immediately preventing any hope of returning the head and neck to the straight position.
Site of pain: The pain will be felt on the side of the neck away from which the head is tilted and this pain will be felt within 5 cm of the midline ranging between the levels of C2 and C7 . Protective deformity: The deformity will consist of varying degrees of lateral flexion away from the side of pain, rotation away from the side of pain and flexion. The element of particular importance in the protective deformity of this entity is that the flexion and rotation components will not be large. Examination movements: With the patient sitting, it will be quite impossible to bring the patient's head and neck into the normal erect straight-on position even if the greatest care to avoid pain is exercised. Palpation for movement on the side of the convexity, using postero-anterior pressure on the articular pillar, (particularly if this posteroanteriar pressure is directed medially), will clearly identify precisely which intervertebral level is involved. Testing for passive physiological intervertebral movement in the direction of lateral flexion will also clearly define the inter-
FIGURE 3: ASSESSING ATLANTO-AXIAL ROTATION. Aust. J. Physiother., 25, 2, April, 1979
53
CERVICAL SPINE EXAMINATION vertebral segment involved. To test in this manner skilfully and expertly requires practice. The following is the description of the technique. C2-C7 (lateral flexion) Starting position: The patient lies supine with his head resting on the table on a pillow, or in the physiotherapist's lap4 The position chosen should facilitate relaxation and it should support the bead and neck midway between flexion and extension for the joint being examined. In this position both lateral flexion and rotation are most free. The physiotherapist places the tip of her index finger into the interlaminar space deeply enough to palpate adjacent laminae. With both hands, particularly the non-palpating hand, she must give adequate support under the occiput. When the lower cervical movements are tested, this support extends under the neck. Method: Being careful to ensure that the joint being tested is moving and not just the head on the neck, the physiotherapist first laterally flexes the joint towards her palpating finger and assesses the extent of closing of the inter-laminar space. The opposite movement is then performed to asses the opening of the space. By this means the excursion of lateral flexion at the Intervertabral level on the SIde beIng tested can clearly be evaluated. The palpating finger tip must remain motionless in the space, so care must be exercised when that finger is used to produce the lateral flexion of the neck.
FIGURE 4: PAIN SCAPULAR AREA4
REFERRAL
TO THE
Protective deformitY.4 As with the previously described disorder, the deformity consists of lateral flexion and rotation away from the side of pain and flexion. The difference between the two deformities is that with this disorder the flexion component of the deformity can be at least equal to the lateral flexion component, if not the main component.
History: The history of this entity is commonly one where the patient reports waking in the morning with a stiff neck. He may, on specific questioning, eventually recall some minor incident of having mildly hurt his neck the previous day The important element in the history which differentiates this kind of protective deformity from the previous entity is that the patient is not wakened during the night by pain, as would have been the case with the above disorder, but rather wakens in the morning with a stiff neck and pain4
Examination movements~' As with the above disorder, when the patient is sitting his head cannot be returned to the upright position, though there is less sharp muscle contraction resisting attempts by the examiner to bring the head upright. On examination by palpation movements, and on examination for the range by passive physiological intervertebral movements (both described above), it is impossible to localise the loss of range to one intervertebral joint; rather the lack of movement is felt to be distributed over three, or more, intervertebrallevels It was stated that the treatment of the two entities is different. The first kind of Wry Neck can be dramatically relieved in one treatment by manipulation or mobilisation. For the second kind of Wry Neck, traction in flexion and sustained oscillatory stretching type rotation of the head away from the painful side will assist spontaneous recovery over a period of days; the greater the flexion deformity, the longer the time taken to achieve the recovery.
Site of pain:
Nerve Root Irritation or Compression:
The pain is felt commonly at the root of the neck on the side away from which the patient tilts his head, and this pain may spread down into the scapular area. In relation to the clinical
When a patient has pain which may be of nerve root distribution and character, this pain mayor may not be accompanied by signs of altered nerve conduction (reflex activity,
Wry Neck (possible discogenic)
4
54
4
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND sensory change and muscle weakness). If nerve root changes are not present the condition is often referred to as one of 'nerve root irritation', whereas when neurological changes are present the condition is usually described as 'nerve root compression'. In the cervical spine, at least, there is no doubt that either irritation or compression of the nerve root can result from disturbances of the disc or the apophyseal joints. This paper concerns itself with the patient who has moderately severe pain spreading the full length of the upper limb, with movements which are limited and reproduce limb pain, but where there is no immediate call for surgery.
Subjective examination: The history, site of pain and behaviour of symptoms are directly relevant in arriving at a probable diagnosis and indication of prognosis. This aspect will not be dealt with in detail in this paper.
Neurological examination: This aspect also will only briefly be mentioned here.. It suffices to say that the therapist must be capable of a very exact examination of individual muscle power, sensation and reflex activity, as well as being able to interpret the findings in terms of which nerve root is involved and the probable intervertebral level involved. In the cervical spine, w hen neurological examination indicates that more than one nerve root is causing the compression signs, this should be seen as a danger signal because it indicates that the disorder is not one which should be being managed by the physiotherapist. It is probably useful to state in this section that C7 is the most common nerve root involved; C6 runs second with C8 and C5 being far less common. When C8 is involved, thoughts of disorders other than disc prolapse should be kept in mind.. When examining the movements of patients who fit into this category, it is necessary to decide whether the movements should be tested up to the point in the range where pain commences or begins to increase, or, on the other hand, whether the movements need to be taken to the limit of the range. When pain is severe or the symptoms are very easily provoked or tend to remain exacerbated, the test movements should only be taken to the point where pain begins. However, movements may be taken beyond this point as will be indicated and described in the section which follows. When a patient's symptoms are mild and chronic, it is probable that the test
Aust.. J. Physiother., 25, 2, April, 1979
movements will need to be taken to the limit of the range. The following examination procedure is that adopted for p~tients with severe pain, with test movements beIng taken to the point of pain.
Passive movement tests: Tests for movement by palpation and tests for passive physiological intervertebral movement have almost no place in the examination of this disorder..
Physiological movement tests: Examination of these movements, with emphatic reference to the behaviour of pain with test movements of this kind, are vital to the assessment and management of this disorder. The movements of flexion, extension, lateral flexion and rotation should be examined with care. The kind of care implied is embodied in the following description of testing, say, lateral flexion towards the side of pain. The steps for the test are as follows . 1. The patient is asked what pain or discomfort he has before testing the movement. 2. The therapist gently holds the patient's head in her hands and asks the patient to tilt his head towards the side of pain, insisting that he stop immediately there is any increase in any part of the symptoms. 3. When the patient stops, the therapist immediately returns the patient's head to the upright position and determines where that pain was felt . 4. Supposing the pain was felt in the scapular area, the movement is repeated to that same point in the range, and the patient's head is held stationary in that position to see whether the pain changes in intensity or area over a period of, say, six seconds. 5. If there is no increase in area of the pain, the movement is carried further into the painful range, the patient having been asked to report immediately any spread of the pain. 6. Immediately the patient indicates any increase in area, the patient's head is returned to the upright position so that the therapist can determine to where the pain had spread. 7. Let us suppose that the pain spread into the upper triceps area. When the patient's head has been returned to the upright position the therapist needs to be certain of the length of time taken for the symptoms to return to their pre-examination intensity and area. 8. When the symptoms have subsided, the movement is repeated to that point in the range where the pain was felt in the triceps. It is then sustained in that position to see whether, over a period of some seconds, the pain spreads further.
55
CER VICAL SPINE EXAMINA TION 9. If the pain spreads further with a sustained position, the head is returned to the upright position and notice is taken of the length of time taken for that pain to subside and the test is completed. 10. If the pain does not spread further with the sustained position, the movement is carried slightly further into the range to see whether the pain spreads further into the arm. 11. If the pain does spread further into the arm, the head is returned to the upright position so that the area of spread can be noted as well as noting the time taken for the pain to subside. 12. If the pain has spread further down the upper arm or reaches into the forearm, the test is then over. With this kind of careful examination it is possible to determine in detail the behaviour of pain associated with movement. It must also be remembered that, although the movement may not increase the intensity or area of the pain at the time of the movement, there is the possibility of latent referred pain which follows movement rather than occurring at the time of movement. Assessment of this behaviour is equally as important, if not more important, than the above. The three movements which commonly reproduce the referred pain are lateral flexion towards the side of pain, rotation towards the side of pain, and extension~ The above description is for those patients whose symptoms are severe and easily exacerbated. The second group consists of those patients whose symptoms are not severe and may be considered chronic. When their pain is not reproduced by these movements, then each of the three movements, lateral flexion towards pain, rotation towards pain, and extension, should be performed as full range movements with slight over-pressure being applied at the limit of the range. This oscillatory over-pressure should be maintained for at least 10 seconds to assess whether the sustaining of the position will reproduce part of the referred symptoms. If the symptoms are not reproduced, then the head is restored to the upright position and a short time, for example, 10 seconds, should be allowed so that assessment of latent pain, referred to above, may be made. There are two other tests which should be undertaken when all of the previous tests have failed to reproduce the symptoms. The first is to examine the lower cervical quadrant. The technique for testing the lower cervical spine by this 'quadrant' movement varies appreciably from that used for the upper cervical spine. To test the lower cervical spine for left-sided pain 56
the neck is tilted back into the left corner until the lower cervical spine is fully extended, laterally flexed to the left and rotated to the left (Figure 5).
FIGURE 5: THE LOWER QUADRANT TEST POSITION.
CERVICAL
The last test involves the application of sustained compression through the head and directed towards the feet, while the patient's head is tilted into slight lateral flexion towards the side of pain and minimal extension. This compression should be applied gently at first, feelingly and with a small degree of oscillation so that the strength of the movement and its effect on symptoms can be continually assessed. Pressure should only be increased if referred pain is not reproduced, and, as with the tests described above, following release of the pressure, a period of waiting should be allowed so that any latent pain can be assessed. Enormously valuable information can be derived from these tests, and they play an immensely important part in the assessment and management of such disorders. When examining patients whose symptoms are chronic in nature, the value of the examination procedures, involving movement by palpation over the articular pillar and spinous processes of the lower cervical vertebrae, is important. However, when symptoms are severe, such examination is unnecessary; the physiological test movements provide all the information that is necessary ~ Whiplash Injury: When a patient's symptoms result from a recent whiplash type injury, the muscles should be tested as a source of pain because they are
Aust. J. Physiother., 25, 2, April, 1979
MAITLAND commonly directly involved by the trauma. They are tested by isometric contractions, starting gently and gradually increasing the strength of the muscular contraction. However, such tests do not supply unequivocal answers because as soon as the muscles are made to contract there is immediately a degree of joint movement. Therefore, when pain is created by the isometric contraction it is difficult to tell how much of this pain is due to the contraction of the muscle and how much is due to the joint movement. It is only by making a comparison between the site and the degree of pain with the isometric contraction, as compared with that produced during an active movement, that any assessment can be made. Muscle tests in disorders other than those caused by trauma usually prove to be uninformative
ACKNOWLEDGMENTS Thanks are due to Butterworths, London, for permission to reproduce text and figures from "Vertebral Manipulation", 4th Edition, 1977, and to Mr David Thompson and the Audio
57
Visual Aids Department of the South Australian Institute of Technology for their part in producing the figures. I would also like to thank Dr. R. Cloward for his helpfulness and generosity in allowing me to refer to his valuable contribution and to reproduce his material.
REFERENCES CLOWARD,R.B. (1960): The Clinical Significance of the Sinu-Vertebral Nerve in Relation to the Cervical Disc Syndrome. Journal ofNeurology, Neurosurgery and Psychiatry, 23:321326~
COPE, S. and RYAN, G.M.S. (1955): "Cervical Vertigo", Lancet, 2: 1355-1358. COPE, S. and RYAN,G.M.S. (1959): "Cervical and Otolith Vertigo". Journal Laryngology and Otology, 73:113-120.
MAITLAND, G.D. (1977): "Vertebral Manipulation", 4th Edition, Butterworths,
London.
Aust. J. Physiother., 25, 2, April, 1979